ment is especially indicated in those who present evidences of tubercular disease.

DENGUE.

Definition and Synonyms.-Dengue is an infectious epidemic disease of warm latitudes, characterized by febrile paroxysms, pain in the muscles and bones, and anomalous eruptions. Synonyms: Dandy fever; Breakbone fever.

Etiology. The disease appears in extensive epidemics confined to the tropics and the sub-tropics. It has occurred in the Southern United States. Large numbers of people are attacked, susceptibility being almost universal. attack does not secure immunity. The disease is supposed to be contagious by personal contact and through fomites. Epidemics occur in the summer months, and are checked by colder weather. The exact poison has not been determined.

Pathology. But little is known about the disease, as fatal cases are rare. There appear to be no essential lesions.

toms.

Symptoms. The period of incubation is about four days. The onset is abrupt, beginning with a chill or chilly feelings, or with convulsions in children. The temperature rapidly rises to 102° to 106° F. according to the severity of the attack, and is accompanied by ordinary febrile sympCerebral symptoms are frequent in the cases with high temperature. At the onset are developed agonizing headache and backache. The muscles are sore and tender. The joints become painful, tender, and frequently red and swollen. The large and the small joints are equally affected. Prostration and depression are marked. In some cases there may appear a transitory erythematous rash. In rare cases there may be severe vomiting and purging. There may be hemorrhages from any of the mucous membranes in severe cases. Lymphatic enlargements are not uncommon. The

febrile paroxysm lasts from three to five days and terminates. by crisis, the fall of temperature frequently reaching the subnormal, although in most cases a moderate fever remains. At the crisis there may be sweating or diarrhoea. As the fever falls the general symptoms disappear, the patient feeling better, though often prostrated and sore.

The period of remission lasts from two to five days, and during it may appear a variety of eruptions which are not distinctive. There may be urticaria, erythematous eruptions of all kinds, or herpes. The severer forms may be followed by desquamation.

After the period of remission there occurs a second paroxysm of fever with a return of all the previous symptoms. This paroxysm, however, is mild and lasts only for two or three days, terminating again by crisis, after which convalescence is established.

Convalescence is usually slow and tedious from mental and physical incapacity.

The prognosis is almost uniformly favorable.

Treatment.-There being no specific treatment, the symptoms must be treated on general principles.

EPIDEMIC CEREBRO-SPINAL MENINGITIS. Definition and Synonym.-Epidemic cerebro-spinal meningitis is an acute infectious disease characterized by inflammation of the cerebral and spinal meninges. Synonym: Cerebro-spinal fever.

Etiology. This disease, which has been recognized only since the early part of the present century, occurs chiefly in epidemics, although sporadic cases are frequently seen. The epidemics are most frequent and severe in the cold. winter months, and are favored by poor hygiene and by the crowding together of people, as in garrisons and barracks. Children are more susceptible than adults. There is no

evidence that the disease may be transmitted by food or by drinking-water. The disease is not considered contagious by either personal contact or through fomites, although rare cases have been reported which render it imprudent to make too dogmatic an assertion in this regard.

In almost all the recently-studied cases there is found in the exudate a lance-shaped coccus which appears identical with the diplococcus of pneumonia, and it appears most likely that this is the specific micro-organism of the disease. It is frequently found associated with the ordinary pus organisms.

Pathology. The brain is usually congested. The veins and sinuses are engorged with blood. The pia mater is infiltrated with an exudate of fibrin, serum, and pus to a greater or lesser degree. The infiltration may be confined to the base or it may be more generally distributed. It is more abundant along the course of the blood-vessels and in the sulci. The lateral ventricles are filled with serum, which may be turbid from admixture of pus. In children, as a rule, and occasionally in adults, this fluid may distend and dilate the ventricles, and in chronic cases after the meningitis has subsided the distention of the ventricles may continue as a chronic hydrocephalus.

The pia mater covering the spinal cord shows similar inflammatory changes, especially on the posterior aspect. The brain-cortex is often infiltrated with pus, which may form small abscesses. The cerebro spinal fluid, which is usually increased, may be turbid. In the exudate the lanceshaped cocci are found frequently with ordinary pus cocci. The lesions may involve the sheaths of the cranial nerves, leading to neuritis and perineuritis. In very malignant cases there may be no time for the lesion to develop before death.

In rare cases the meningitis is of the cellular variety. The

pia may appear normal or lustreless or congested. There is neither fibrin, serum, nor pus, but there is a marked proliferation of the connective-tissue cells of the pia. These cases usually run a different clinical course.

The remaining lesions are not distinctive, being those common to all severe infectious diseases. There may be hemorrhages in the skin, in the serous membranes, and into the viscera. There is granular and fatty degeneration of the liver- and kidney-cells and of the heart-muscle. The spleen is usually enlarged and soft.

Symptoms. The period of incubation is usually short, varying from a few hours to several days. During this time the patients may complain of headache, slight feverishness, and lassitude.

The onset is usually abrupt, being marked by a chill, fever, headache, and vomiting. The fever may reach to 102 or 104° F., and does not run any typical course. While high fever belongs to the severe cases, the reverse is not always true. In some cases the fever may not be marked.

The headache is usually frontal, but it may be parietal, occipital, or general. It is a severe headache, persisting during sleep and periods of stupor, as evinced by moaning, clasping the head with the hands, or by the facial aspects of pain. There may be general pains in the bones and muscles.

The vomiting is frequently severe and distressing, and does not depend upon the giving of food or of drink. It may assume a projectile character.

During the earlier stages of the disease there are nervous symptoms of irritation. The headache has already been mentioned. There are frequently psychical disturbances, as shown by delirium, which may be maniacal. Some patients show morbid erotic desires. There may be from time to

time a sudden sharp cry, the so-called "hydrocephalic cry." The functions of the cranial nerves are exalted. There are photophobia, usually with some amount of conjunctivitis, intolerance to sounds, facial neuralgia, and muscular twitching.

The irritation of the spinal nerves is shown by pain, tenderness, and contraction of the muscles of the back of the neck that may amount to opisthotonos if the muscles of the trunk are similarly involved.

The skin is hyperæsthetic, the least touch causing exquisite pain. General exaggerated reflexes are highly characteristic. There are twitchings and spasms, and frequently automatic movements of the muscles of the arms or legs. The attitude is one of flexion.

The pulse is at first increased in proportion to the fever, becoming slowed and full when the brain begins to be compressed by the effusion and distention of the ventricles. It is often remarkably variable in its rapidity.

Various atypical eruptions may be seen on the skin. Herpes on the lips or the face occurs in half the cases. As the herpetic vesicles frequently contain the characteristic micrococci of the disease, bacterial examinations may be serviceable in confirming the diagnosis. There may be erythematous blotches or urticaria or petechial spots, which may be so grouped as to suggest a nervous origin.

The urine usually contains small amounts of albumin and casts. There may be polyuria. Glycosuria has been observed in a certain number of cases.

Digestive symptoms are not pronounced, with the exception of the initial vomiting. The bowels are usually obstinately constipated. In a few cases a complicating dysentery has been observed. The abdominal wall may be markedly retracted, presenting a "boat-shaped" appearance. There may be severe abdominal pain.